A50-43 Recognizing Pulmonary Nocardiosis in the Immunocompetent Patient

Abstract Introduction Nocardia species are environmental, opportunistic pathogens capable of causing severe infections, particularly in immunocompromised individuals. Although frequently dismissed as laboratory contaminants, Nocardia should be considered a potential etiologic agent in symptomatic patients without a clear alternative diagnosis. In the United States, the estimated annual incidence ranges from 500 to 1,000 cases, with approximately 60% occurring in immunocompromised hosts, 1 such as those with HIV, on long-term glucocorticoid therapy, or with polysubstance abuse. Nocardia infections may involve multiple organ systems, most commonly the pulmonary, cutaneous, and central nervous systems. Rarely, Nocardia can affect immunocompetent individuals. Case Report We present a case of a 50-year-old uninsured male with a past medical history of chronic obstructive pulmonary disease, traumatic brain injury, dental caries, tobacco and marijuana use disorder. He presented with worsening shortness of breath, nasal secretions, productive cough with non-bloody sputum, fever up to 103 °F and leukocytosis. The patient has documented anaphylactic allergic reactions to sulfa drugs and penicillin. On examination, he was anxious, agitated, diaphoretic, tripoding, and exhibited perioral cyanosis while on a BIPAP. Despite administration of IV lorazepam, his agitation persisted, leading to self-removal of his peripheral IV and BIPAP. He then rapidly decompensated, requiring intubation and ICU admission. A bronchoscopy soon followed, demonstrating thick white plaques in the distal trachea and left mainstem bronchus. This prompted further evaluation for HIV, which was negative, and a bronchoalveolar lavage and sputum cultures which identified many branching acid-fast bacilli consistent with Nocardia species. Despite his anaphylactic reaction to sulfa, the severity of infection necessitated desensitization to trimethoprim-sulfamethoxazole (Bactrim), the first-line antibiotic. He was successfully extubated and discharged on a six-month course of oral Bactrim. Discussion This case highlights the importance of considering Nocardia as a potential pathogen even in immunocompetent patients. It also underscores the clinical utility of antibiotic desensitization in patients with severe infections and limited therapeutic options due to drug allergies. Physicians should maintain a high index of suspicion for Nocardia in atypical presentations of pulmonary infection, regardless of immune status, and be prepared to pursue desensitization protocols when first-line therapies are contraindicated. Citation Duggal, S. D., & Chugh, T. D. (2020). Nocardiosis: a neglected disease. Medical Principles and Practice, 29(6), 514-523. https://doi.org/10.1159/000508717 This abstract is funded by: None